Provider Demographics
NPI:1700989266
Name:PORTER, MICHELLE M (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:M
Last Name:PORTER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S. CHRISTIAN
Mailing Address - Street 2:PO BOX 743
Mailing Address - City:MOUNDRIDGE
Mailing Address - State:KS
Mailing Address - Zip Code:67107-0743
Mailing Address - Country:US
Mailing Address - Phone:620-345-3000
Mailing Address - Fax:620-345-3042
Practice Address - Street 1:121 S. CHRISTIAN AVE.
Practice Address - Street 2:
Practice Address - City:MOUNDRIDGE
Practice Address - State:KS
Practice Address - Zip Code:67107-0743
Practice Address - Country:US
Practice Address - Phone:620-345-3000
Practice Address - Fax:620-345-3042
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-01284225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS013616Medicare ID - Type Unspecified